syncope( -

Syncope

Steen Juul-Möller, MD, PhD, FESC Dpt. of Cardiology Skane University Hospital, Malmö, Sweden

”ECG Monitoring”

…there are many kinds…

…some TLOC`s have a permanent impact…

…others are of a more paroxysmal nature…

… and some are mostly to show the world …

..that I am a misunderstood Darling!

The first quesEon is

Why? Vessel tone?

Heart? Europace, 2002;4:351-‐356

56%

14%

Heart! Structural

or

Arrhythmia

Europace, 2002;4:351-‐356

3%

11%

Arrhythmia?

Only one requirement! You need an

ECG-‐strip from the event! As always, a few excepEons: • Slow AF or AFl • AV block 2-‐3 • Extreme sinus bradycardia • Trifascicular block • WPW/Brugada Syndrome, etc.

Our methods:

• 12-‐lead ECG

Our methods:

• 12-‐lead ECG • 1/2/7 days Ambulatory ECG (Holter)

The original Holter biotelemetry Apparatus. From 1947, Weighing 38 kg

The original Holter biotelemetry Apparatus In 1947, weighing 85 lb (38 kg)

118 g splashproof

The original Holter biotelemetry Apparatus. From 1947, Weighing 38 kg

Our methods:


• External Loop Recorder

Our methods:


• External Loop Recorder • Ambulatory short-‐strip ECG

Our methods:



• Implantable Cardiac Monitor

Our methods:



• Implantable Cardiac Monitor

• Pacemaker/ICD

• In-‐Hospital ECG monitoring

We want to get the culprit-‐ECG as easy and efficient as we can!

At the ECG-‐lab in Malmö we perform 3400 Holters/year. We perform all kind of

ECG-‐invesEgaEons.

This report demonstrates the

diagnosEc efficacy 2008-‐2009.

StaEsEcs 2008-‐2009 n=6250

24 hours Holter 62%

48 hours 23%

7 days 15%

External Loop Recorder 60/year

ICM 18/year

The DiagnosEc QuesEons > one question in 20%

Syncope: Types

22 Europace, 2002;4:351-‐356

Syncope: Types

23 Europace, 2002;4:351-‐356

Syncope: Types

24 Europace, 2002;4:351-‐356

Did we answer the clinical quesEon? (All invesEgaEons from 2009; n=3200)

Next step: External Loop-‐recorder! 2008-‐9 years invesEgaEons; n=120

No symptoms: No ECG Mean dura4on: 4.2 weeks (2-‐14 wks)

ECG during symptoms

18 of the 120 paEents w/ External Loop-‐Recorder had syncope during

the test.

Bradycardia: 2 paEents (11%)

18 of the 120 paEents w/ External Loop-‐Recorder had syncope during

the test.

Normal sinus rhythm: 72%

Single extra beats: 17%

Bradycardia: 2 paEents (11%)

… the last resort … Implantable Cardiac Monitor

6250 Holters

Arrhythmia (63%)

Syncope (n=25%)

Inconclusive in 35%

Ischemia (25%)

Other (6%)

External Loop Recorder (n=120) Inconclusive in 29%

ICM (n=36) 5% of all Syncope patients

For the years 2008-‐9:

The diagnosEc efficacy of ICM has been evaluated in the

PICTURE-‐study

Primary Objec4ve • To evaluate the Eme to diagnosis in relaEon to the Eming of the Reveal implant during the diagnosEc workup.

Secondary Objec4ves • Determine diagnosEc yield • Describe the standard care pathway • Evaluate the total burden of diagnosEc tests (early use vs. late use) • Determine the raEo between diagnosis “cardiac related” and “non-‐cardiac

related”. • RelaEonship between results of diagnosEc tests and Reveal diagnosis. • Differences in recurrence rate syncope vs. presyncope • Determine the relaEonship between # preceding syncopal events vs. Eme to

diagnosis.

PICTURE – Primary and secondary objecEves

PICTURE study plan

• PICTURE was a prospecEve, mulE-‐centre, observaEonal post-‐markeEng study conducted from November 2006 unEl October 2009

• 88 parEcipaEng sites in 11 countries (Austria, the Czech Republic, Denmark, Finland, France, Germany, Israel, The Netherlands, the Slovak Republic, Sweden and Switzerland). A total of 72 sites contributed to paEent enrolment.

PICTURE study plan • PaEents were eligible if they had recurrent unexplained syncope or pre-‐syncope.

• PaEents were followed up unEl the first recurrence of a syncopal event leading to a diagnosis or for at least 1 year.

• 650 paEents enrolled (2006-‐2008)

• 570 paEents followed-‐up

• Average Follow-‐Up Eme: 10±6 months

Time to recurrence of syncope, ater Reveal implant

• During follow-‐up a total of 218 paEents (38% of the populaEon) experienced an episode of syncope, 149 with prodromal symptoms

• The percentages of paEents that had a recurrence of syncope were 19%, 26% and 36% ater 3, 6 and 12 months respecEvely (black line)

• 10% of paEents with an episode during follow-‐up had associated severe trauma.

Recurrence of Syncope, first year: 36%

DiagnosEc yield of Reveal • Time to a syncopal event where

Reveal played a role in the diagnosis showed the recurrence of diagnosis within 180 days as 20%, within 365 days as 30% and within 462 days as 38% (grey line)

• The esEmated rate of syncope ater 30 days of follow-‐up was 10% and the esEmated rate of diagnosis where Reveal played a role at this Eme of follow-‐up was 9%

ICM played a diagnosEc role, first year: 30%

Conclusion: • 11% of paEents with Syncope have Arrhythmogenic Syncope.

• The majority (67%) can be evaluated using Holter. DiagnosEc in 65%.

• External Event Recorder is needed by 25%. DiagnosEc in 11% of those with Syncope.

• ICM is indicated in 5% of the Syncope paEents in whom a diagnosis can be obtained in

30% within 1 year .

Arrhythmic Syncope EvaluaEon:

11%

89%

100%

67%

25%

5%

Arrh. Syncope

Other Syncope

1-‐7 d Holter

External Event Recorder

Implantable Cardiac Monitor

1-‐7 d

4 weeks

> 1 year

Conclusion:

We get them all…

eventually!!

Thank You For your attention!

It is over!!

syncope( -

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